Arthroscopic Subcoracoid Decompression, Coracoplasty, and Subscapularis Repair for Subscapularis Tears in the Setting of Subcoracoid Impingement.

Subscapularis tears have been found to occur in the setting of subcoracoid impingement and are related to the narrowing of the coracohumeral interval. The advancement of arthroscopic techniques has allowed for improved identification and treatment of this historically overlooked pathology. Challenges of arthroscopic subscapularis treatment include nearby neurovascular structures, tendon retraction, and adhesions, which are further complicated by diminished arthroscopic visualization, resulting from the concomitant subcoracoid impingement. The purpose of this Technical Note is to describe our preferred technique for arthroscopic management of subscapularis tears in the setting of subcoracoid impingement that is simple and reproducible, as well as cost-effective and efficient with limited additional morbidity to that of a standard diagnostic shoulder arthroscopy.

Introduction

Partial and complete subscapularis tears have been found to occur in the setting of subcoracoid impingement.1, 2, 3 The normal value of the coracohumeral distance has been estimated to range between 8.7 and 11 mm and the narrowing of this interval has been implemented in the development of subscapularis pathology and anterior shoulder pain.3, 4, 5 Historically, limited attention was paid to the subscapularis and its associated pathology. As arthroscopic techniques have progressed over the last 30 years, the identification and treatment of subscapularis injuries have become more common. Some challenges that have presented in the evolution of the treatment of subscapularis tears include its proximity to neurovascular structures, particularly when mobilization is required due to retraction and adhesion formation; and limited viewing within the subcoracoid space, especially when there is subcoracoid impingement present.

Herein, we present a technique for arthroscopic management of subscapularis tears in the setting of subcoracoid impingement that is simple and reproducible in addressing the above historical concerns of treating subscapularis pathology in the coracohumeral interval. Research was performed at the Steadman Philippon Research Institute (Vail, CO).

Surgical Technique

A narrated video with demonstration of the surgical technique described may be reviewed (Video 1).

Patient Positioning and Anesthesia

In the preoperative holding area, an indwelling interscalene catheter is placed for postoperative pain control by the anesthesia pain service. After transfer to the operating room and induction of general anesthesia, the patient is positioned in the beach chair position with the head of the bed elevated to approximately 60°. A pneumatic arm positioner is used throughout the procedure.

Diagnostic Arthroscopy and Subcoracoid Space Debridement

Following a surgical safety timeout, administration of antibiotics, and a preoperative examination under anesthesia, a posterior portal is established, and a comprehensive diagnostic arthroscopy is completed. Next, a rotator interval portal is established using an outside-in needle localization technique. This portal is purposely positioned both superiorly and laterally in the rotator interval to allow for ease of access to the subcoracoid space and coracoid. Prior to making a skin incision, an 18-gauge spinal needle is used in order to confirm appropriate trajectory and access to the coracoid tip (Fig 1). A 5-mm cannula (Arthrex, Naples, FL) is then placed after a 7-mm skin incision is made with a #11 blade (Fig 1). A diagnostic arthroscopy is performed, and the pathoanatomy is identified in the upper border of the subscapularis tendon and long head biceps tendon. Next, using a combination of a 4.0-mm shaver and radiofrequency device, adhesions, thickened anterior capsule, and bursal tissue are carefully removed until the anterior border of the subscapularis tendon, as well as the entirety of the coracoid and conjoint tendon are completely visible (Fig 2). Additionally, a biceps tenotomy is carried out at this time using the radiofrequency device (Fig 2).

Fig 1

View of right shoulder from posterolateral portal with the patient in the beach chair position. (A) An 18-gauge spinal needle is used to establish the rotator interval portal and confirm appropriate trajectory and access to the coracoid tip. (B) A 5-mm cannula (Arthrex, Naples, FL) is then placed after a 5-mm skin incision is made with a #11 blade.

Fig 2

View of right shoulder from posterolateral portal with the patient in the beach chair position. (A) A bipolar radiofrequency device is introduced into the glenohumeral joint and used to ablate the synovitis around the subscapularis in the rotator interval and subcoracoid space. (B) A long head biceps tenotomy is performed utilizing the radiofrequency device.

Subcoracoid Decompression and Coracoplasty

Next, a radiofrequency wand is used to skeletonize the posterior surface of the coracoid. Care is taken not to disturb the conjoint tendon. A 4.0-mm arthroscopic shaver is then used to perform a coracoplasty to create a space of at least 8 mm (Fig 3).

Fig 3

View of right shoulder from posterolateral portal with the patient in the beach chair position. A 4.0-mm arthroscopic shaver is then used to the perform a coracoplasty.

Subscapularis Tendon Repair

While viewing the subscapularis tendon tear from the posterior portal using a 30-degree arthroscope, a 4.0-mm shaver is used on burr mode to lightly decorticate the superior portion of the lesser tuberosity in the region where the upper rolled border of the subscapularis tendon is torn to create a bleeding bone recipient site for tendon repair (Fig 4). Next, an 18-gauge spinal needle is placed percutaneously in a low anterior position and identified anterior to the subscapularis tendon. It is then passed through the subscapularis tendon in the desired location and identified intra-articularly. Next, the spinal needle stylet is removed and a #0 PDS suture is fed through the needle and retrieved using a grasping device through the anterior cannula after the spinal needle is carefully withdrawn (Fig 5). Next, the PDS suture is used to shuttle a FiberTape suture (Arthrex, Naples, FL) through the subscapularis tendon (Fig 5). A 4.75-mm awl (Arthrex, Naples, FL) is then used to create a socket for an anchor in the previously decorticated subscapularis footprint in the lesser tuberosity (Fig 6). Both limbs of the previously passed FiberTape are then fed through the eyelet of a 4.75-mm polyetheretherketone SwiveLock anchor (Arthrex, Naples, FL). The SwiveLock anchor is then passed through the anterior portal into the piloted hole, each limb of the FiberTape is individually tensioned, and the anchor is inserted to restore the subscapularis tendon back to the lesser tuberosity (Fig 6). The FiberTape ends are then cut flush. Secure reduction and fixation are tested with an arthroscopic probe and during arm range of motion (Fig 7).

Fig 4

View of right shoulder from posterolateral portal with patient in the beach chair position. The subscapularis tendon is visualized (A) and a 4.0-mm shaver is used to lightly decorticate the superior portion of the lesser tuberosity to create a bleeding bone recipient site for tendon repair (B).

Fig 5

View of right shoulder from posterolateral portal with the patient in the beach chair position. (A) An 18-gauge spinal needle is placed percutaneously through the subscapularis tendon, and a #0 PDS suture is fed through the needle. (B) The PDS suture is used to shuttle a FiberTape suture (Arthrex, Naples, FL) through the subscapularis tendon.

Fig 6

View of right shoulder from posterolateral portal with the patient in the beach chair position. (A) A 4.75-mm awl (Arthrex, Naples, FL) is used to pilot a hole in the previously decorticated subscapularis footprint in the lesser tuberosity. (B) The FiberTape suture is then fed through the eyelet of a 4.75-mm polyetheretherketone SwiveLock anchor (Arthrex, Naples, FL), and the anchor is deployed for repair of the subscapularis tendon back to the insertional footprint.

Fig 7

View of right shoulder from posterolateral portal with the patient in the beach chair position. Secure reduction and fixation are tested with an arthroscopic probe.

Procedure Completion and Closure

Next, the remaining intraarticular pathology of the rotator cuff and long head of the biceps tendon is addressed as needed. The biceps is tenodesed using a subpectoral technique, as described elsewhere. After copious irrigation, meticulous hemostasis is achieved, and the portals are closed using interrupted, buried absorbable sutures.

Postoperative Rehabilitation

A sling is used for 3 weeks. Physical therapy and passive range of motion with a 30-degree external rotation limit is started immediately. Full active range of motion commences at 3 weeks.

Discussion

The presented technique allows the surgeon to perform a subcoracoid decompression and subscapularis repair using the standard portals for a diagnostic shoulder arthroscopy, a single knotless suture anchor, and percutaneous access with a spinal needle resulting in a safe, efficient, and cost-effective method for this historically challenging pathology. There have been numerous techniques published regarding arthroscopic treatment of subscapularis pathology; however, we believe that this technique is both simple and reproducible with excellent results, as reported by Katthagen et al. and others.9, 10, 11, 12, 13, 14, 15, 16, 17, 18 Additionally, our stepwise approach with decompression of the subcoracoid space allows for safe manipulation of the subscapularis tendon in proximity to the neurovascular structures medially and inferiorly.

Barlow et al. have also described a single portal technique; however, their usage of a 25° QuickPass SutureLasso (Arthrex, Naples, FL) device is not as cost-effective, and more user-dependent than simply introducing a spinal needle into the location of the tendon, where suture-passage is desired. The spinal needle method avoids the cost of other high-end suture passing devices that some authors have advocated, and it also negates the need for establishment of an anterosuperolateral portal, as is described by Howlett et al. Although most subscapularis tears associated with subcoracoid impingement can be treated with the technique described in this article, the same methods can be applied to larger tears, for which a double-row technique and multiple rows of linked anchors can be used. Lastly, there is no need for knot-tying, which creates more consistency, decreases the risk for soft tissue irritation, and reduces the risk for loss of repair tension. Several other techniques have been presented; however, they have similar pitfalls as mentioned above.,

While the benefits of our presented technique are evident as discussed above, there are also technical pitfalls that, if not avoided, can potentially make decompression and repair very challenging (Table 1). If the anterosuperior portal is established in a too medial or too superior of a position, it can be challenging to perform an adequate decompression and coracoplasty. Therefore, a midlateral placement of this portal is warranted. Medial and/or inferior placement may also prohibit appropriate angulation of the suture anchor insertion. Additionally, if attention is not paid to the coracohumeral distance, the inadequate coracoplasty or failure to perform a coracoplasty can make instrumentation difficult within the space anteriorly. If visualization or instrumentation is still difficult, we have a low threshold to employ a 70° arthroscope to view the subscapularis tendon insertional footprint on the lesser tuberosity, and we use an assistant to apply a posterior-directed force on the humerus to improve our working field.

Table 1

Pearls and Pitfalls

Pearls	Pitfalls
When a coracoplasty is considered based upon preoperative imaging, the anterior portal should be positioned more laterally to provide an appropriate trajectory for instruments to reach the posterior aspect of the coracoid.	Placement of the anterior portal in a medial position will make both the debridement of tissue anterior to the subscapularis and the coracoplasty difficult.
A gentle posterior force on the proximal humerus by an assistant is helpful to increase the working space for anterior capsular debridement, subscapularis repair, and coracoplasty. A 70° scope can also be helpful to improve visualization.	When placing the anterior cannula, resistance may be encountered if penetrating the coracoacromial ligament (CAL). If encountered, the cannula tip should be redirected inferiorly to avoid CAL penetration.
A thorough debridement of the anterior rotator interval, scar, and capsule anterior to the subscapularis tendon is necessary prior to suture passage through the subscapularis tendon.	Subcoracoid impingement is considered a space between the coracoid tip and the subscapularis of less than 8 mm. Failure to increase this distance can make placing instrumentation difficult within the space anteriorly.
A 70° arthroscope can be used from the posterior portal if visualization of the subcoracoid space is impaired or difficult.

Although this is a comparatively safe technique to address subscapularis pathology, the procedure is not without risk. Risks associated with this technique align with other approaches to arthroscopic management of subscapularis tears and include the potential for neurovascular injury with inferior and/or medial release of the subscapularis tendon, as well as instrumentation of these regions. There is also a low risk of proximal humerus fracture with anchor placement. Additionally, if the tear is at the musculotendinous junction or the tendon is severely retracted, addressing the pathology may require an open approach rather than the arthroscopic technique described in this Technical Note.

Pathology of the rotator interval structures is often interconnected. Impingement between the coracoid and the lesser tuberosity can be a source of shoulder pain as well as cause injury to the subscapularis and anterosuperior rotator cuff. Other rotator interval structures can also become involved, including biceps pulley lesions or subscapularis tears that lead to biceps instability and tendonitis or tearing. Our described technique aims to address all of these concomitant pathologies. Clinical outcomes using this technique have been previously reported with excellent results at a minimum of 2-year follow-up. Single-anchor repair of the subscapularis with biceps tenodesis resulted in American Shoulder and Elbow Surgeons (ASES) scores of 93.7 in Lafosse type II tears, and 86.7 in Lafosse type I tears. In a series by Vap et al., 14 patients with biceps reflection pulley lesions treated with subpectoral biceps tenodesis achieved excellent outcomes, including improvements in ASES, Quick Disabilities of the Arm Shoulder and Hand, and Short-Form-12 Physical Component Scores.

In conclusion, we present a technique for arthroscopic management of subscapularis tears in the setting of subcoracoid impingement that is simple and reproducible, as well as cost-effective and efficient with limited additional morbidity to that of a standard diagnostic shoulder arthroscopy.